Plymouth County Mosquito Control Project

School Request for Mosquito Spraying

Name of School   ______________________________    

 Name of Town/City  ______________________  Address____________________________

 Date of Requested Spraying:

Describe the area(s) to be sprayed:

Children’s and Families Protection Act Check List

1. The school has submitted an inside and outside IPM plan to the DAR.  ______

2.  The IPM plan includes the Plymouth Country Mosquito Control Project and lists both

         of the following pesticides:  

·         Anvil 10 + 10, with Sumethrin and Piperonyl as the active ingredients, EPA reg. number 1021-1688-8329.

·         Duet, with Prallethrin, Sumethrin and Piperonyl as the active ingredients, EPA reg. number 1021-1795-8329.

·         Please check if both are included in your IPM plan. _____

3. The school will follow the guidelines for “standard written notification” as outlined in the Children’s and Families Protection Act ________.

  The Project will fax or email schools the Standard Written Notification form and related materials that you will distribute.  

Standard Written Notification is not required if no school sponsored activities are scheduled for five or more consecutive days after the pesticide application.                Check here if this applies _____

If the above does not apply, please indicate with a check mark the method to be used for notification:

Optional method A, use of email _____

                        Optional method B, website   _____

                        Notification by hard copy - C  _____  

4.  The Project will be responsible for the posting and removal of pesticide warning signs.

Title of Person making the request:

Signature of Person making the request:

Please Fax this completed request form to PCMCP at 781-582-1276